Stress fracture in a runner
Running involves a lot of aches and pains and it is hard to work out what to be worried about and what not to be. However, the dreaded ache at rest, in a bony area, such as the foot is when alarm bells go off.
This club runner, ‘Jess’, had been running well for a few months with nothing more than a bit of soreness on the inside of her left shin after a long run or a session. It settled in a few days and a bit of a massage and she thought nothing more of it. After a cross country race one Saturday however there was a new pain in the top of the left foot, on the bone – the 2nd metatarsal. It built up through the day and was most apparent by the evening while on the sofa and it woke her up overnight and was particularly painful to weight bear the next morning.
Sensibly Jess didn’t attempt the long Sunday run she had planned with her friends but rested the foot, applied ice and took some ibuprofen.
It didn’t behave the way a sore muscle does though. It was sore to touch with a very small amount of swelling and hurt to take weight through the foot but was achy rather than sharp. Moving the toes was a bit sore but not a lot. The ache grew as Jess walked on it and was particularly achy at rest. Muscles or tendons don’t do that!
After a couple of days of limping around Jess decided she needed to get it seen so was able to get a GP appointment. The GP was not sure and again just advised rest and ibuprofen. Jess was not filled with confidence given the lack of clear diagnosis so booked an appointment for the end of the week with us.
By this point, Jess had not run on the foot for 6 days as she was aware there was something wrong. However, with this rest, it was feeling somewhat better. The ache at night had stopped and whilst the foot was a bit tender after walking on it for an hour, the demands of University did not bother it.
Jess said that she had not had any previous issues in the left foot but that the medial shin pain had been intermittent for several months and occasionally there was a soreness in the lower back after a hilly run. General health was good and she enjoyed a good mixed diet and had regular menstrual cycles and no other previous running injuries since becoming more serious about it in the last 4 years. Jess ran typically around 30 miles a week but that since starting University and joining the club the intensity of the sessions and even the steady runs had probably been higher than when she was at home.
With this history clear, I assessed Jess by firstly looking at how she used the left foot in standing, knee bends, tiptoes and hops. There was a little tenderness on tiptoe and hop but mild. Watching the foot whole leg it was apparent that the knee rotated inwards over the foot and that there was more pronation (rolling in) of the foot on landing. Jess was unable to fully lift up to tiptoe due to apparent weakness in the foot/calf.
Due to the mild history of lower back issues, I checked the back and found that there was considerable stiffness to the left side of the lumbar spine. reduced trunk rotation and poor lower rib inspiration as well as a clearly poorly rotating sacroiliac joint. This to me was significant as a possible cause of the internal leg rotation and original medial shin pain and ultimately the excessive twisting through the foot and thus the recent pain.
On the bed, we found further signs of sacroiliac joint dysfunction as well as a tender spot on the top central part of the 2nd metatarsal. This was the classic very tender spot about the width of the fingertip with a mild tenderness either side and not a lot above or below that. Careful palpation showed that it was on the bone and it had that curious slight bony softness – life a layer of rubber, on the bone itself. This is the swelling in the periosteum – the bony cover around our bones – and if often felt with periostitis and a bone stress reaction.
There was a weakness in the foot invertors as well as the deep lateral gluteal muscles. Typical of lower back neural irritation.
So, the diagnosis was clear, It was a bone stress reaction with likely a fracture. There was an underlying lower back / SIJ issue which had altered the leg mechanics and caused the issue in the shin and the foot. We treated this with manual therapy to get the lower back and sacroiliac joint working correctly again and set exercises to maintain this. Once we had corrected this spinal issue the foot strength and the gluteal strength returned significantly showing that the issue was primarily neural inhibition. However, we set simple glut work in any case to stimulate the muscle.
I would have liked to have set footwork but we could not due to the main issue of a bone stress reaction/fracture. Given the acute tenderness and the night pain, my experience said that there was likely to be a fracture line here. Jess was not insured and we felt that whilst an MRI would be nice it would not alter the treatment approach. So, sadly, Jess went into a boot for a minimum of 3 weeks. As it had settled a bit with rest in the first few days I did not feel Jess needed to use crutches at this stage and being at University and not travelling or needing to load the foot much during the day was a good scenario. However, we agreed that if there was still pain in a couple of weeks we would have to add crutches in.
It is typical of a stress fracture for it to feel better and the patient to feel that it is just a strain. When you then load it again the symptoms come rushing back, often worse than before. It may feel draconian to go in a boot but it is the surest and fastest way to get these issues to heal.
Jess had a number of exercises to do to work on her glut and lower back/pelvis, but nothing that loaded the foot. Jess was going to talk to her GP about a Vitamin D test and bone mineral assessment as these can contribute to bone stress. My view is that the lower back and pelvic issues had altered Jess’ biomechanics and that this was the primary cause. There did not seem to be any obvious training increases but for the speed of some runs might have been a little more in recent months.
Jess was very diligent with her use of the boot and when we met up again in 3 weeks she had not felt any pain or symptoms for 10 days. There remained some tenderness to palpate the bone but this is typical and can be present for some months. The rubbery feel had settled as had the bit of swelling. As there had been 10 days of no pain I was happy to ask Jess to come out of the boot and go into trainers. This was on the condition that she continued to rest and to be very careful and honest with herself about her symptoms. Any recurrence, however mild, needed the boot to go back on.
We assessed the lower back again and found the SIJ to be moving normally. There was a bit of lower back stiffness and we mobilised this out. I felt this was likely to be due to Jess using the boot.
We agreed to meet up in another 3 weeks to hopefully begin the return to running protocol and to add further work in to improve the gait and control in the foot and whole leg.
In 3 weeks Jess returned and she had been pain-free for the past few weeks and had been careful with only the supermarket walk and a couple of nights out. There was still a little tenderness in the bone but no other symptoms. The back was much better and there were no signs of the SIJ dysfunction.
We were able to get Jess onto the return to running protocol we use for this type of stress fracture – a simple build up to 30 minutes of running over 3 weeks. We added in several feet and leg strength exercises as well as specific control and stability work to build Jess’ leg control and impact mitigation. We had to be cautious as the bone had recovered but remained very vulnerable to a rapid onset of loading.
We agreed to meet again in a fortnight to assess progress and review gait pattern from some self videos of the running which will be around 15 minutes at that point. I asked Jess to take these in a particular way to give me the most information.
Jess progressed well and managed to alter her gait significantly during the return to running phase – the best use of this period. We moved onto a full training programme from 10 weeks since the injury and with a much-improved gait pattern. We still review the lower back and pelvis as this was the cause and is a common issue in runners. The medial shin tightness is used by Jess as a sort of early warning signal that things are not being as controlled as they might and she is now aware of how the back feels so does the work herself to manage it and occasionally seeks input from me.
Jess has recovered fully and is back running and enjoying racing and, with the expert input from her coach at Loughborough University is progressing well.